9.7.1 Examining the contributory factors in drug errors and their reporting to introduce a new drug error reporting scheme (352)

Gerry Armitage, Senior Research Fellow, Quality & Safety Research Office, Bradford Institute for Health Research, Bradford, United Kingdom

Abstract:

Background:

Drug errors account for 10-20% of all adverse events (DoH, 2004). The response has ultimately raised the profile of incident (or error) reporting although reporting is not without its imperfections (Armitage & Chapman 2007).

Aim:

To examine the contributory factors in drug errors and their reporting to introduce a new reporting scheme in a British acute hospitals trust.

Methods:

A retrospective, random sample of 991 definitive drug error reports from 1999-2003 were subjected to a quantitative and qualitative analysis, followed by 40 qualitative interviews with a volunteer, multi-disciplinary sample of health professionals. The combined data were used to introduce a new reporting scheme which was piloted in the host trust for 3 months in Summer 2006.

Results:

The randomly selected reports differed in quality, 25% lacking contributory factors. There was sometimes a sole focus on individuals culminating in blame without obvious justification. Doctors submitted far less reports than nurses. Interruptions, high workload and the chaos of practice were predominant contributory factors in interviews. The predominant organisational orientation to error was perceived as individual rather than systems-based. Reporting was portrayed as a thankless treadmill. The new (pilot) scheme employed structured cues and guided free text. Existing reporting rates were maintained, with an increase in some units. Drug error types were recorded in each report and contributory factors in all but one. There was no qualitative evidence of individual blame.

Discussion & conclusion:

Reporting schemes can increase learning and decrease inherited blame if carefully structured and managed. Reporting can be a dynamic part of risk management, indicative of a learning culture which regardless of discipline raises error analysis at the point of reporting. Action taken should be an active, discerning response to human performance in the context of local conditions, and organisational priorities.

Recommended reading list:

  • Armitage G. Chapman EJ. (2007). Incident reporting is not an effective tool (as it exists) in improving patient safety. Journal of Integrated Care Pathways 9 1-6
  • Armitage G. Newell RJ. Wright J. (2007). "Drug errors and their reporting in a British acute hospital trust. Clinical Governance 12 (2)
  • Department of Health (2004). Building a Safer NHS for Patients: Improving medication safety. HMSO: London

Source of Funding: UK - Health Service (National)

Amount in Funding: 100,001 - 500,000

Biography:

Gerry Armitage worked as a registered nurse for 13 years in both junior and senior posts. Following this he spent a similar length of time working in higher education where he led pre and post registration nursing programmes and developed new courses with the NHS, independent sector, and outside the UK. He recently completed a 3 year research study funded by the Department of Health which culminated in the introduction of a drug error reporting system for an acute hospitals trust. He is currently leading a study funded by the Parkinson’s Disease Society to examine the quality of care planning in residential care, including medicines management. He is also leading a multi-disciplinary research team in evaluating the role of electronic health records in reducing prescribing errors on acute admission to elderly care. He has published in the field of child health, drug errors and incident reporting.